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CERTFiOLDER COPY <br />SC <br />P.O. BOX 420807, SAN FRANCiSCO,CA 94742 -0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSU2 DATE: 02 -07 -2011 <br />CITY OF SANTA ANA SC <br />PLANNZNO AND BUILDING AGENCY <br />PD BOX 1898 <br />SANTA ANA CA 92702 -1968 <br />GROUP: <br />POLICY NUMBER 16818(31 -2010 <br />CERTIFICATE ID; 21 <br />CERTIFICATE EXPIRES: 09 -01 -2011 <br />OB -01 - 2010 /OB -01 -2011 <br />This is to certify that we have issued a valid Workers' Compensation Insurance policy In a form approved by the <br />Callfornla insurance Commissioner to the employer named bestow for the policy period Indicated. <br />Th1s policy Is not subject to cancellation by the Fund except upon 30 tlays advance written notice to the employer. <br />We will also give you 30 days advance notice should this pcifcy 6e cancelled prior to Its normal explratlan. <br />Th15 certificate of Insurance is not an insurance policy and does not amend, extend or alter the coverage afforded <br />by the policy listed herein Notwlfhstandingg any requirement, term or condrilon of any contract or other document <br />with respect to which this certificate of insurance may be Issued or to which It may pertain, the Insurance <br />afforded by [ha policy tlescrl6ad herein Is Subject to all the terms, exclusions, -and conditions, of such policy. <br />f � `H)S�tt�a L <br />Authorized Representative President end CEO <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $t, 000,000 PER OCCURRENCE. <br />ENDORSEMENT N20BB ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE OB -01 -2010 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />O AS TO FORM <br />6� I <br />R O.H <br />t• City Attotnney <br />EMPLOYER <br />CENTURY STRUCTURAL ENGINEERIN9 CO. INC. SC <br />24719 NARBONNE AVE <br />LOMITA CA 90717 <br />(MJL,CNj <br />PRINTED 02 -07 -2011 <br />W E V.9 -20 701 <br />